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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003654
Report Date: 01/13/2023
Date Signed: 01/13/2023 01:56:55 PM


Document Has Been Signed on 01/13/2023 01:56 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE & INLAND A/SC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868



FACILITY NAME:TESSIE'S PLACE LOVING CARE HOME #1FACILITY NUMBER:
306003654
ADMINISTRATOR:NOEL GUTIERREZFACILITY TYPE:
740
ADDRESS:27642 ROSEDALE DRIVETELEPHONE:
(949) 487-0529
CITY:SAN JUAN CAPISTRANOSTATE: CAZIP CODE:
92675
CAPACITY:6CENSUS: 5DATE:
01/13/2023
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Marie Ramos, caregiverTIME COMPLETED:
02:30 PM
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On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unnanounced visit to the facility for the purpose of following up on the plan of corrections for deficiencies observed during the annual visit conducted on 12/15/2022. LPA was greeted and granted entry by caregiving staff and explained the purpose of the visit.

During the annual inspection visit on 12/15/2022, LPA observed laundry detergent left accessible due to unlocked door. A type B deficiency was cited.

As part of the present visit, LPA was able to confirm that all potentially dangerous items were made inaccessible to individuals in care. Laundry detergent are being stored under lock in the laundry area cabinets. Kitchen cleaning supplies are locked under the sink. In-service training of facility staff on the secure storage of potentially dangerous items and substances has been conducted.

The plan of corrections for the deficiency was cleared during today's visit. An exit interview was conducted and a copy of this report along with a plan of corrections clearance letter were printed and left with facility representative.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Kevin Saborit-GuaschTELEPHONE: (714) 497-8754
LICENSING EVALUATOR SIGNATURE:
DATE: 01/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/13/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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